445294156-6-20-2023-26-AS-KHOS-CU3KVT-20230725081452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 445294156
Report Date: 06/20/2023
Date Signed: 06/20/2023 02:48:09 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/30/2020 and conducted by Evaluator Ryker Heberle

COMPLAINT CONTROL NUMBER: 26-AS-20201230104312

FACILITY NAME:	BROOKDALE SCOTTS VALLEY		FACILITY NUMBER:	445294156
ADMINISTRATOR:	HARRISON, PAUL		FACILITY TYPE:	740
ADDRESS:	100 LOCKEWOOD LN		TELEPHONE:	(831) 438-7533
CITY:	SCOTTS VALLEY	STATE: CA	ZIP CODE:	95066
CAPACITY:	220	CENSUS:	DATE:	06/20/2023
		UNANNOUNCED	TIME BEGAN:	01:37 PM
MET WITH:	Beena Kumar		TIME COMPLETED:	02:51 PM

ALLEGATION(S):

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Unqualified staff administered medications to residents.
Facility did not provide food of the quality and quantity necessary to meet residents' needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ryker Heberle conducted an unannoucned visit to deliver the findings from an investigation on the above allegations. LPA met with facility administrator Beena Kumar (Administrator)

The Department interviewed 10 members of facility staff and 8 residents of the facility. Of the staff members interviewed, 1 out of 10 stated that while they had never personally been asked to deliver medication to residents, they believed that unqualified facility staff members (including maintenance people and housekeepers) had administered medication to residents. 9 out of 10 staff members interviewed stated that they had not administered medication, nor heard of unqualified staff administering medication. During audit of medication cabinet, no medications were noted to be missing, and all medications were found in their proper place.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 26-AS-20201230104312

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: BROOKDALE SCOTTS VALLEY	FACILITY NUMBER: 445294156
	VISIT DATE: 06/20/2023

NARRATIVE

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In interviews with facility residents, 8 out of 8 residents stated that they did not believe they were ever administered medication from improper staff. When asked if they were ever delivered or administered medication by housekeeping or maintenance staff, 8 out of 8 residents stated that they did not believe so.

8 out of 8 residents were asked if they were delivered food during the COVID-19 outbreak. 8 out of 8 residents stated that they were delivered food three times a day during the outbreak. 7 out of 8 residents stated that food was of adequate quantity and quality. One resident (R1) stated that food often arrives cold, and doesn't taste very good. When asked if they receive enough food, R1 stated that they get enough, but they don't like the food so they don't eat all of it. 8 out of 8 residents interviewed stated that the food had decent variety, and adhered to the menu distributed to residents.

Based on information from interviews conducted, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations are UNSUBSTANTIATED.

No deficiencies cited under Title 22 during this visit. This report was reivewed with facility administrator Beena Kumar and a signed copy of the report was provided.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: Ryker Heberle	TELEPHONE: 714-328-5152
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023

LIC9099 (FAS) - (06/04)

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